Anna Sadovnikova

Background: Among persons of childbearing age, advanced chronic kidney disease (stage 3–5) reportedly affects approximately 1 in 150 individuals. Birth rates compared to the general population are lower in kidney transplant recipients and in individuals undergoing dialysis, estimated at approximately 1:10 and 1:100, respectively. Despite these challenges, the incidence of pregnancy among those with chronic kidney disease is increasing, and birthing parents with advanced chronic kidney disease, including those undergoing dialysis or with a kidney transplantation, express a strong desire to breastfeed prenatally and initiate breastfeeding after childbirth. However, the factors influencing breastfeeding outcomes and their milk composition in birthing parents with kidney disease are not well understood. At present, no clinical practice guidelines exist to specifically address lactation management for birthing parents with kidney disease, leaving a gap in support and care for this population. Aims: Our primary aims are to describe lactation outcomes and define milk composition for birthing parents with advanced chronic kidney disease, post-kidney transplantation, or receiving dialysis therapy. Our secondary aims are to describe the breastfeeding experience, including attitudes, self-efficacy, and challenges, and evaluate infant health outcomes including developmental and medical history. Methods: We are conducting a prospective observational cohort study in California, using mixed methods to examine lactation outcomes, breastfeeding experience, parent-infant health, and milk composition among participants ( N ≈ 10) with chronic kidney disease, kidney transplantation or dialysis. Participants will complete surveys, oral interviews, breastfeeding telemedicine consultations, 24-hour infant test-weighing, and milk sample collection. Control participants without kidney disease and with either normal (600–1035 mL) or low (< 600 mL) milk supply will be recruited. Milk composition (macronutrients, metabolome, electrolytes, cytokines, and immunoglobulins) will be compared. We will use descriptive statistics to summarize participant characteristics, and inductive thematic analysis to generate contextual insight into lactation patterns and birthing parent experiences. Discussion: Outcomes of this study will guide practice recommendations for the multidisciplinary care team supporting birthing parents with advanced chronic kidney disease, kidney transplantation or undergoing dialysis, ensuring breastfeeding safety and appropriate support.

Nipple pain is a common reason for premature breastfeeding cessation. There exists anecdotal evidence that one cause of lactational nipple pain is a ductal obstruction, but there is no published literature describing this phenomenon. Herein we present two case reports for two patients who experienced breast and nipple pain concurrent with milk flow reduction. Both patients removed a small stone-like obstructing object from their nipple; this action was painful for one of the patients, resulting in immediate release of milk and relief from breast pain. Both patients experienced recurrence of stone formation in their nipple ducts. We analyzed the mineral composition of the obstructing objects and breast milk using inductively coupled mass spectroscopy. We use literature on teat obstructions in dairy cows and dacryolith and sialolith formation to propose hypotheses as to how the formation of obstructing objects in milk ducts might occur. Future research directions for determining the pathophysiology, clinical presentation, and management of human nipple duct obstructions are discussed.

Objectives:Physicians may be asked to prescribe, recommend, or discuss foods, herbs, and medications for low milk supply. It is unclear how factors such as education, experience, and regulations influence clinical practice. The objective was to document physicians’ clinical practice surrounding pharmacologic, nutritional, and herbal products for the management of low milk supply.Methods:Physicians from two Facebook groups completed an anonymous, online survey about their clinical use of pharmaceutical, supplemental, and nutritional substances perceived to increase milk production. The association between practice patterns and lactation medicine expertise or country for different perceived galactagogues was determined.Results:A total of 307 physicians completed the primary portion of the survey. There was no difference in the proportion of physicians in Canada or the United States (U.S.) who were defined as lactation medicine experts. Canadian physicians were more likely to prescribe metformin, levothyroxine, and domperidone for low milk supply compared with U.S.-based physicians. Canadians and experts were more likely than U.S.-based and nonexpert physicians, respectively, to include herbs in their practice. Patient request, personal and clinical experience, and lack of education, research, or access were frequently selected as reasons for or against using a specific substance.Conclusions:The U.S. Food and Drug Administration ban on domperidone affects low milk supply management in North America. Though Canadian physicians prescribed domperidone without limitations, U.S. physicians were less likely to incorporate it into clinical practice. Despite a lack of evidence, physicians in North America frequently used herbs and foods to increase milk production.

Introduction: Existing literature on pregnant patients with chronic kidney disease (CKD) with or without kidney transplantation focuses mainly on their pregnancy outcomes, but there are scant data on their lactation outcomes. Our objective was to characterize the lactation outcomes of patients with CKD with or without kidney transplantation. Methods: This is a single-institution retrospective cohort study of female-identifying patients with CKD with or without kidney transplantation who had a birth hospitalization at a tertiary health system between 2010 and 2020. Maternal and pediatric data on medical history, pregnancy, delivery, neonatal, and lactation outcomes, medications, and care team involved were collected. Primary outcome measures were breastfeeding initiation within 24-hour postpartum, breastfeeding 8 or more times per day during hospitalization, and any breastfeeding beyond 1 month. Health professionals' comments related to lactation and medications were extracted for qualitative data analysis. Results: Patients with and without kidney transplantation had similar comorbidities, pregnancy, delivery, and neonatal outcomes, and hospital length of stay (p > 0.05). Patients without kidney transplantation were more likely to initiate breastfeeding in the first 24 hours (p = 0.03) after delivery and continue breastfeeding beyond 1 month postpartum. There was a lack of consistency between specialties regarding medication compatibility with lactation. Patients on immunosuppression were more likely to exclusively formula feed (p = 0.02) or to initiate breastfeeding and then switch to formula (p = 0.0004) because of their immunosuppressive medications versus patients on any other medication. Conclusion: Patients with CKD but without a kidney transplantation were more likely to initiate breastfeeding or provide breast milk to their infant within 24 hours of delivery, breastfeed >8 times per day during their hospital stay, and breastfeed beyond a month postpartum than those with a transplanted kidney. Lactation support and pharmacology should be incorporated into graduate medical education.

Introduction Patients turn to foods, herbs, and medications to increase milk supply (i.e., galactagogues). Physicians may be asked to prescribe, recommend, or discuss perceived galactagogues despite a lack of evidence for their use. It is unclear how factors such as education, experience, and regulations influence clinical practice. The primary objective of this study was to document Canadian and US-based physicians’ attitudes towards, practice patterns surrounding, and utilization of pharmacologic, nutritional, and herbal products for the management of low milk supply. A secondary objective of this study was to determine factors that influence physicians’ decision-making with respect to the use of pharmacologic agents, foods, and vitamin, mineral, and herbal supplements for the treatment of low milk supply. Methods Physicians were recruited from two Facebook groups to complete an anonymous, online survey about their clinical use of pharmaceutical, supplemental, and nutritional substances perceived to increase milk production. The association between practice patterns and lactation medicine expertise or country for different perceived galactagogues was determined. Results A total of 307 physicians completed the primary portion of the survey. There was no difference in the proportion of physicians in Canada or the United States (US) who were defined as lactation medicine experts. Canadian physicians were more likely to prescribe metformin, levothyroxine, and domperidone, despite limited evidence of their effectiveness as galactagogues. Experts used all of the pharmacologic galactagogues. Canadians and experts were more likely than US-based and non-expert physicians, respectively, to include herbs in their practice. Numerous reasons for recommending or not recommending a given agent were cited, including patient request, personal and clinical experience, and lack of education, research, or access. Discussion The US FDA ban on domperidone affects which pharmacologic agents physicians in North America prescribe for low milk production. Despite having access to domperidone and limited evidence of their effectiveness, Canadian physicians are more likely than US physicians to also discuss, recommend, or prescribe herbal supplements as galactagogues. Conclusion In this online survey about medications, herbs, and foods commonly used in an effort to increase milk supply, Canadian and US-based physicians with and without lactation medicine expertise described their practice patterns and reported limitations in knowledge, medication access, and evidence. Though Canadian physicians prescribed domperidone without limitations, US physicians were less likely to incorporate it into clinical practice.

Introduction: Breast and skin assessment are both required clinical skills across health professional training programs. The breast is an ideal “canvas” for the development of a simulation exercise focused on the identification and diagnosis of skin conditions that could present anywhere on the body alongside unique conditions specific to the breast and nipple-areolar complex. A skin assessment simulation on a breast model has not been described. Methods: Investigators developed 20 clinical vignettes for breast and skin conditions (ie, features) depicted on a set of 10 single silicone breast models in 4 skin tones. A modified Delphi approach was used to evaluate the appropriateness of the clinical vignettes and realism of features. A convenience sample of 136 licensed physicians was recruited online. In round 1, participants rated the realism of features and suggested descriptors for each feature. In round 2, participants rated their agreement with descriptors from round 1, selected a diagnosis based on clinical vignettes, and assessed the utility of the Breast Health Training Tool for health professionals. Results: In round 1, participants (n = 38) agreed (5.1/6) that the features were realistic. In round 2, participants (n = 24) agreed (4.6/6) with the descriptors. Most (>50%) participants agreed on a diagnosis for each feature. Participants (n = 27) agreed (5.3/6) that this tool is useful for health professional education. Conclusions: This is the first evaluation of a simulation tool for teaching breast examination and identification of skin conditions on the nipple-areolar complex and breast tissue in multiple skin tones, simultaneously filling the gap in women's breast, lactation, and skin health education.

Objective: The aims of this pilot feasibility study were to determine if telesimulations with standardized patients (SPs) wearing high-fidelity breast models impact students' team behavior and clinical competence in lactation support. Materials and Methods: Medical students (N = 19) completed five telesimulations: Cases 1, 2, 5 in a team, 3 as individual, and 4 randomized. SPs used the Formative Assessment Rubric (FAR) to evaluate interpersonal and clinical competence. Collaboration skills within team-based telesimulations (Cases 2 and 4) were rated using the Interprofessional Collaborator Assessment Rubric (ICAR). Satisfaction data were collected from a focus group and written evaluation. Descriptive statistics were calculated for FAR, ICAR, and written evaluations. Appropriate nonparametric tests were used to measure FAR and ICAR differences over time or between team and individual telesimulations and the relationship between FAR and ICAR scores. Content analysis was used to generate themes from focus group data. Results: Learners' interpersonal and lactation-specific competence improved over time (p = 0.003 and 0.009, respectively). Learners were able “to accept responsibility for their actions” more but spent less time “seeking perspectives from peers” in Case 4 compared with Case 2 (p = 0.01 and p < 0.001, respectively). Themes from the focus group related to the value of team telesimulations to learn clinical lactation skills and learn about one's role in a team. Learners agreed they developed clinical lactation skills (>4.5/5-pt). Conclusions: Opportunities to work collaboratively in telesimulations with a SP prepare learners for professional collaborations to effectively care for breast/chestfeeding dyads.

Milk is critical for the survival of all mammalian offspring, where its production by a mammary gland is also positively associated with its lactose concentration. A clearer understanding of the factors that regulate lactose synthesis stands to direct strategies for improving neonatal health while also highlighting opportunities to manipulate and improve milk production and composition. In this review we draw a cross-species comparison of the extra- and intramammary factors that regulate lactose synthesis, with a special focus on humans, dairy animals, and rodents. We outline the various factors known to influence lactose synthesis including diet, hormones, and substrate supply, as well as the intracellular molecular and genetic mechanisms. We also discuss the strengths and limitations of various in vivo and in vitro systems for the study of lactose synthesis, which remains an important research gap.